The strength of the MRI is not the only thing

[Quixotic1]

I have inadvertently mislead the forum into thinking that the strength of the MRI machine is the only thing that determines quality or the ability to discern tiny lesions.  For a long time I thought that this was true.  But, in the last year I have been learning that the software and the techniques used are also critically important.  I have mentioned this here and there in posts, but have not talked about it with the full forum.

The software that analyzes the electromagnetic signals has grown in elegance and sophistication by leaps and lightyears.  My neuro discussed this briefly with me last year.  He stated that the 3.0T MRI at the nearby university (OHSU) had really mediocre software, so he was continuing to send his patients to the private imaging center that is associated with Providence Health Systems.  this center uses the most elegant software.

I am beginning to realize that a good 1.5T MRI with the latest/best software can be superior to a humdrum 3.0T machine.

Also, they are developing new techniques for the magnetic pulsing and it's analysis that increase the yield in seeing MS lesions.  My newest MRI (last winter) noted that several of my lesions were "more prominent".  But, the report went on to say that a couple more sophisticated techniques, like Double Inversion Recovery and 3D Inversion had been used and this "may" have made the same, old lesions stand out more.

So, we cannot talk in absolutes of "3T vs 1.5T" machines any more.  I know this takes away a lot of what we thought we knew in terms of assessing how good our MRIs were.  This is unfortunate, but it is a reality.  Since I have no way to know or understand what these software tecniques are, then I can no longer assume that any old 3T machine is way better than a 1.5T machine.  I believe that in general a 3T is superior, but the 1.5T can apparently be enhanced a great deal.

The most recent recommendations for the MRI protocol for the diagnosis of MS (put out not long ago by the Consortium for MS Centers) has DROPPED the recommendation that the lowest acceptable MRI strength is 1.0T.  They make no lowest requirement.  Instead, they discuss that the standard of quality should be the resolution of the images.  Shell (sllowe) will be reporting on these new recommendations soon.  I assume that this requirement was dropped, because new advances in software and techniques allow even the lower strength MRIs to give much better images than before.

So....this leaves us with no way to know with any assurance how good our films are.  This makes the whole "negative MRI" harder to evaluate.  Unfortunately, some of our neurologists do not seem to be aware of how good the MRI machines they use really are - or aren't.

I have continued to hear comments by neuros that closed machines are superior to the open ones, but I am also aware that the software is improving for the open ones.

Sorry about all this, but real info that we can't assess is better than believing something false that may lead us to make erroneous conclusions.

Quix

[twopack]

I'm just now getting to my MS diagnosis but have had several MRIs for back pain in the past.  One last year (thoracic and lumbar) took so long to complete that I was in tears from lying on my back and then I didn't think I'd be able to move off the table.

When I had brain and lumbar MRIs last month, it seemed they were done in a flash even though there were additonal scans for contrast.  

So what makes the difference in time?  Is there a slice per minute program or is it the machine?

And what the MS protocol?  How do you know if it's used?

Thanks.  I'm new to all this and just ramping up to speed on info.

~Mary

[mackemuk]

Hiya Quix Hope You Are Keeping Well.
Having Just Read What You Have Written I Agree With You Entirley.
The Reason I Say This Is Because I Am Going For Another MRI The Last One Being July 2008 Which As You Know Was On A 1.5T Scanner,However My Hospital Has Just Installed A New 1.5T Scanner
(Siemens Avanto scanner) Which Is Apparently More Powerful And Faster And The Best In Producing More Detailed Images Even Thou It Is The Same Telsa As The Old One Which Was By The Way 10 Years Old.
It Just Goes To Show How Advanced These Scanners Are, Because If The 3T Scanner Was Better I Am Sure My Hospital Would Have Went For That One Instead.
I Think As You Say It Boils Down To The Advanced Software And Different Sequences They Use Now.
But No Way Am I Dismissing The 3t Scanner As I Am Sure They Play Their Role In Helping Diagnosing MS, It Is Just That The New 1.5T Scanners Seem On The Face Of It On Par With The More Powerful Scanners.
Well Thats The End Of My Contribution And I Hope Everyone Keeps Well In Themselve's And Take Good Care.
Oh By The Way This New Scanner Is Supposed To Be The Best In North-east England And That My Friends Is A Big Area To Make That Sort Of Claim.
Take Care Everyone And You Quix.
Regards Joe.

[Ufrustrated2]

really good information for us all. thanks for posting it. more power to us as our own health advocates!

[Karen99]

I was thinking a lot about these doctor situations many of us find ourselves in.  I accompanied my mother to her oncologist appointment today.    

She is a great doctor.  What makes her so great?  She looks you in the eye.  She stands near you. Listens. Explains. Listens. Explains and explains more.  There is no great deal of effort the patient has to expend to feel comfortable with the process whatever stage a patient is in - Pre or post diagnosis.    

In my observation, what makes a fantastic MS neurologist is one who is curious, intrigued, and has a true interest in MS and the patient.  Their interest is almost palpable when they enter the room.  They look straight at you and ACTUALLY listen to what you have to say. Once they hear what you have to say, it's like they can hardly contain themselves to do a neurological exam to see what they can find.  Of course I am exaggerating here, but those of you who have a good neuro knows what I'm talking about.  

When you find a doctor like that, you can trust them, but it is never a good thing to set your own thinking aside totally.  Doctors are only people after all and medicine is not an exact science.  

During the time before I was diagnosed I kept telling my rheumatologist that I felt my central nervous system was involved in my symptoms.  I was suspicious of MS or MG.  She was a mediocre doctor but I did not know where else to go.  At that point in time I was running the show.  Heck, I wanted to get my moneys worth.  The good outcome of that was almost all of the MS mimics were ruled out. When I finally got to a neurologist that work was done.

I attended an MS conference a couple years ago and the featured speaker, an esteemed MS neurologist said that far as patients go, multiple sclerosis patients were generally the most educated and informed group in respect to their MS.

I'm due for another MRI soon.  As a patient I won't need to demand a 3T because my neurologist sends me to the best facility; best machine, best software.  One time I went to another facility because it was closer.  OMG.  What a difference.  The images were horrible and the report stunk.  Their "MS Protocol" wasn't up to par either.  I called ahead before my MRI appointment to make sure they were up to par.  They weren't.  They wanted hundreds of dollars that my insurance did not cover.  That MRI was basically useless and wasted my money.  I did not pay them and told them why.  Never got another bill from them.

[Nancy T]

I should add that what generates trust within a patient is when the doctor EXPLAINS things in a way that MAKES SENSE and fits with the patient's facts. This is why I love my current PCP and PT. They listen, look, and then explain things, based on what they find or don't find. Thus, I feel I can trust them, and guess what? Then I am a "compliant" patient! (Yes, I'm doing my back exercises faithfully! :)

Gone off-topic, though...

[Nancy T]

Quix wrote: "We all need doctors that LOOK at us, LISTEN to us and THINK.  These are the docs that we can TRUST."

A huge DITTO to that! The doctors that use unbiased observation and logic, rather than jumping to conclusions and ignoring facts that don't fit their convenient conclusions, are very different from the rest of the pack.

Out of the 17 MDs in whose offices I've sat in the past 10 years (including 7 family practitioners or internists, 4 neuros, 3 ENTs, and one each for eyes, spine, and rheumatology), there have been only three that I felt were REALLY listening, paying attention, smart, and trying seriously to solve my problem(s). Seven of them jumped immediately to false conclusions and never even tried to get to the bottom of anything. The rest were somewhere in between (though mostly good or at least OK).

(Fortunately, my current PCP and now a great PT are among the cream of the crop!)

Quix, you have undoubtedly caused far more good than harm here. Even if you were mistaken on something (as we all sometimes are, inevitably), it's of course up to every person how they interpret and use the information posted here. I doubt you encouraged anyone to diagnose themselves wrongly.

Nancy

[Fluffysmom]

I wish there was a directory of doctors that look, listen and think.  

My first three neuros would not be in the directory
.
#4 was quite clearly recognizable as the best kind of doc. I do trust him, and am very happy to have been sent in his direction.

Kathy

[Quixotic1]

Good points there.  I need to go through and find where I have encouraged people to diagnose themselves suing comments I made.  In this kind of situation I may be causing more harm than good.

To all - We all need doctors that LOOK at us, LISTEN to us and THINK.  These are the docs that we can TRUST.  We will recognize these docs when we see them.  Then we need to let them make the diagnostic decisions.  

Quix

[Fluffysmom]

Thanks for the great information; it's nice to know how things are progressing.

A few years ago I talked to a vendor at a radiology conference, who told me that images would improve as software improved when we were discussing the strenght of machines.  Who would have thought that OHSU wouldn't have had the lastest greatest software?

At least my brain MRI was much better than the spine, and good enough to get me started on Avonex.   Dr. C. seemed to be disgusted by the quality of the C-spine images; said they could have done better there, motioning toward the hospital.

I'm glad that he'll be the one to order my next MRIs, whenever they'll happen, and send me to the place with the best equipment and software.  It sounds like yours was done with new techniques that give a clearer picture; we're all for that.

Maybe the nurse will tell me when I'll most likely have a follow-up MRI when she shows me how to inject my Avonex on Monday.  

Kathy

[Nancy T]

An MRI tech on another forum was making the same point for ages--that 3T is not necessarily better than 1.5T. He says (and I hope I'm not misquoting) that it depends on the software and on the skill with which the MRI is performed and interpreted.

The exhortation "you need to insist on a 3T machine," which has been so frequently seen here, is an example (I think) of how much patients--desperately needing or wanting a diagnosis--want to boil down complicated information or situations (technology, test results, what the neuro did or didn't do) into relatively simple beliefs or "truths," which we tend to reinforce among ourselves. What appears to be gospel truth in one decade (women should be on HRT) or from one perspective (3T is better) may turn out to be wrong, or just one part of a more complicated story.

Certainly it's good to try to inform oneself, to listen to other patients' knowledge and experiences, and to have a healthy skepticism about the medical establishment (as about everything else).

But personally, I think the best thing to do is, if you're looking for a proper diagnosis and appropriate treatment, use what you know to find a doctor that you TRUST. Then listen to and work with that doctor, until and unless you have reason to no longer trust him or her. Ask questions, be informed, but remember that the doctor has more experience and (usually!) more expertise in diagnosing and treating disease, which can be WAY more complicated than we think.

I just don't think that patients should, for the most part, be demanding tests or demanding that tests be performed on certain equipment in the first place. If you feel that you have to DEMAND something like that, then most likely you either don't need the test, or you need to find a new doctor who will take you seriously. But of course, we don't always know these things in the moment... hindsight is 20/20.

This is all just my personal view; your mileage may vary. Some people are more comfortable being their own doctor than I am.

Thanks for posting this info for everyone, Quix.

Nancy

[Udkas]

I have had 3 MRI done last year and all were done on T3 machines but all 3 were performed on different T3 machines.  I have copies of all the pictures.  The machines were identical brand, similar age, pretty new, different hospitals, different operators, different software, different technique possibly.

The quality varies greatly, which amazed me, but my daughter's fiancee who is a radiographer told me that it is also the speed that they put them through as well, my best pictures and clearest etc. was at the private hospital where my MRI of my thoracic and Cervical spine took a long time to do, the same with the other government hospital but I had the same procedure done at another government hospital that's machine was only 3 weeks old and it took less than 30 min, pics were not as good?

So apparently it can depend on the operator as well, I know mine were done using MS protocol.

Interesting point and I did discuss this with my neuro and he agreed that it did rely on the software and even to the skill of who is reporting on your films as different radiologist interpret the films differently, so I have covered all odds and gone to 3 different places but always taken my old films for comparison..

Cheers,
Udkas.

[cassrox]

Good point. When she made no bones about how bad the image quality was, I knew I had finally found the right doctor.

Thanks Quix!

[Quixotic1]

When your neuro stated the images were in chunks, she was likely referring to the fact that they took slices from one part of the brain or cord, then jumped and took some more slices, etc.  This is a technique used to look for big things like tumors and cysts, but is not adequate to see the sometimes very small lesions of MS.

The requirements for doing an MRI for the purpose of diagnosing MS require that the slices be continuous - one right after another - and in extremely thin slices (1 - 3mm).  The type of MRI you describe probably used slices of 5 or 10mm which would esilay miss a lesion that was just 3mm in size.

It IS all in the equipment.  We all want the best resolution we can get, which will be a combination of magnet strength, advanced equipment, software sophistication and proper techniques.  It comes down to finding a neuro who can tell a good MRI from a bad one and who will send you to the best available in the area.  Unfortunately this is not something we can evaluate, unless we find someone like you have who says, "These images s*ck!"

Quix

[cassrox]

The ms specialist I finally got to see Tuesday was not impressed at all with the images I had done 1 1/2 years ago. She said they were in "chunks" and the quality wasn't good. I assumed it was because they were done on a 1.5T, but now that you brought this up, I guess it's possible that the software wasn't up to snuff - or it could be a combination of both. The machine was actually housed in a semi trailer, which didn't impress me too much at the time....I guess with good reason.

Dr. H did make the comment that "it's all  the equipment," and that there was no way she was sending me back to the same place I had the first ones done because those images did her little good in terms of making a diagnosis.

I'm still waiting to hear when I have to go for the new MRIs done in Greenville. I have no idea what kind of software they're using or the strength of the machine, but she sure seems much more confident in the equipment there. I would guess it's probably the best in this area.

[LATW]

What you explained about the software is exactly what a friend told me her neuro said to her.

Thank you for posting this.  Now I know she was right! HA!!  ;-}